Covid-19 Online Consent Form

Patient Request for Treatment,
Representations and Consent

I acknowledge and understand that there is an increased risk that COVID-19 can be transmitted in any place of public accommodation, including a dental office. Even after following protocols set by the American Dental Association and our state dental association, it is still possible to contract COVID-19 while at a dental office.  This office is following all guidelines to minimize the risk of transmission while you are seeking care. 

However, it is important to understand that social distancing of 6 feet is not possible while the dental practitioner and authorized staff are in the physical act of providing dental care that you need.  In addition, the COVID-19 virus has an incubation period during which carriers of this virus may not show signs or symptoms and may still be contagious.

I consent to the performance of the treatment proposed by my dentist.


I agree that any form of electronic signature, including but not limited to signatures via facsimile, scanning, or electronic mail, may substitute for the original signature and shall have the same legal effect as the original signature.